Title: Texas Elder Abuse and Mistreatment Institute
1Texas Elder Abuse and Mistreatment Institute
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2 Module 2 INTERVIEWING ELDERS, ELDERLY VICTIMS,
and PERPETRATORS Part A Geriatric Assessment
and Decision-making Capacity
- E. Lee Poythress, M.D.
- Baylor College of Medicine
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3Module 2 Objectives
- Use general interviewing skills with the elderly.
- Review the clinical interview and describe how it
pertains to geriatric assessment and
intervention. - Describe methods for determining mental capacity.
- Define neutralization and its various types.
- Demonstrate neutralization techniques.
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4Pre-Test Questions
- 1. Which of the following is true regarding
geriatric assessment and intervention (GAI)? - a. It is best applied in the hospital
setting. - b. It can be performed by a licensed social
worker. - c. It has been shown to delay diagnosis at
- times.
- d. It involves a comprehensive
- multidimensional evaluation.
- e. It is a proven intervention for elder
- mistreatment.
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5Pre-Test Questions
- In Texas, which of the following professionals
can determine decision-making capacity? - a. Social workers
- b. Police officers
- c. Prosecutors
- d. Physicians
- e. Psychologists
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6General Approach to the Elderly Patient
- Elderly patients often present with complex,
chronic issues. - Elder mistreatment victims often live in
precarious social situations. - Initial assessment can be a significant
undertaking.
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7General Approach to the Elderly Patient
- Allow for extra time on a visit or consider
breaking up the visit into two closely spaced
meetings. - 2. Geriatric Assessment Intervention (GAI)
techniques are a structured way to evaluate the
elderly. - 3. Autonomic dysfunction set room temperature
at 70-80 degrees Fahrenheit.
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8General Approach (cont.)
- 4. Aid vision and communication by using bright
light and large-print literature and by sitting
face to face. - 5. Presbycusis speak in a lower pitch without
significantly raising the voice, sit face to
face, and use headphones. - 6. Central processing auditory deficit quiet
rooms. - 7. Privacy.
Cassel, 1997
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9General Approach (cont.)
- 8. Normal aging comes with a slowing of
performance, but not decreased cognition. - 9. Family members or caregivers often accompany
patients. Remember to respect autonomy. - 10. Dementia or cognitive impairment does not
mean incapacity.
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10The Clinical Interview and Geriatric Assessment
and Intervention
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11Clinical Evaluation GAI
- Geriatric Assessment and Intervention (GAI)
- Comprehensive history and physical.
- Assessment of cognitive and functional status.
- Full social evaluation.
- Tailored items (Physical Therapy -Occupational
Therapy screen, audiovisual screen, other).
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12Clinical Evaluation GAI
- Usually composed of a team Medical Doctor,
Nurse Practitioner, Physicians Assistant,
Physical Therapist/Occupational Therapist, Social
Worker, nurse managers, etc. - Shown in multiple care settings to improve
outcomes, decrease readmission rates, and improve
quality of life. - Office-based adjustments can be made.
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13Clinical Evaluation GAI
- Primary care physicians may be reluctant to get
involved in all forms of family violence (AMA
Guidelines, 1992). - Time and reimbursement issues are real.
- GAI can help with these matters.
- Dont give up!
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14Clinical Evaluation GAI
- Social History
- Important for all forms of abuse and neglect.
- Essential components
- Living arrangements?
- Home utilities working?
- History of family violence?
- Drug or alcohol use by patient or caregivers?
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15Clinical Evaluation GAI
- Essential components
- Finances/monthly income Who manages money (pays
bills, cashes checks, etc.)? - Social contacts?
- Food supply Who buys it? Who prepares it?
- How did patient get to the clinic?
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16Clinical Evaluation GAI
- Depression Screening and Cognitive and Functional
Assessment -
- Key component of GAI.
- Use of brief, accepted screening tools.
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17Clinical Evaluation
- Other evaluations
- Complete blood count
- Serum chemistries
- X-rays
- Toxin screens
- Drug levels
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18Conclusions
- Interviewing elderly patients requires some
adjustments in approach. - The theories and risk factors surrounding elderly
mistreatment can act as important tools when
evaluating patients. - GAI is an efficient and reliable way to evaluate
elderly patients.
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19Decision-making Capacity
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20Decision-making Capacity
- Competence refers to a persons capacity to
make rational, informed decisions about his or
her care. (Oyama O, 1999) - Medical competence refers to a persons ability
to understand medical information and make
informed medical decisions. - Competence legal term
- Decision-making capacity medical term
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21Decision-making Capacity
- Formal competence assessment usually takes place
after evidence calls a patients capacity into
question (in a medical setting). - Primary clinicians can perform assessment.
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22Decision-making Capacity
- Competence is a legal determination based partly
on a medical assessment. - Final ruling is judicial.
- A person can have a mental health disorder, such
as Alzheimers disease, and show signs of obvious
impairment, and still be legally competent.
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23Methods of Competency TestingMiller, S.S. and
Marin, D.B. (2000)
- Many instruments have been developed for
assessing patients competence. There is no
universal standard. - Physicians are primarily focused on medical
decision-making capacity.
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24Methods of Competency Testing
- Basic tenets of assessing medical decision-making
capacity can be used to assess a patients
capacity to make rational, informed decisions in
other areas of life. - When filling out capacity assessment forms for
court, you are asked to extrapolate.
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25Applebaum and Grisso, 1988
- 1. Communicating choices.
- 2. Understanding relevant information.
- 3. Appreciating the situation and its
- consequences.
- 4. Manipulating information rationally.
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26Annas and Densberger, 1984
- What is your present physical condition?
- What treatment is being recommended for you?
- 3. What do you and your doctor think might
happen if you decide to accept the treatment?
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27Annas and Densberger, 1984 (cont.)
- What do you and your doctor think might happen if
you decide not to accept the treatment? - 5. What alternatives are available? What are the
probable consequences of each one?
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28Documentation
- Document using either the Applebaum and Grisso
method or the Annas and Densberger method and
address each topic as it pertains to your
patient.
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29Conclusions
- Primary care physicians can assess competence in
most clinical situations. - There are no accepted standards for this.
- Primary care clinician focuses on medical
decision-making capacity but, in competency
situations, will be asked to extrapolate.
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30Conclusions
- Both the Applebaum and Grisso method and the
Annas and Densberger method provide a solid
framework for discussing patients medical
decision-making capacity and court-evaluated
competency.
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31Post-Test Questions
- 1. Which of the following is true regarding
geriatric assessment and intervention? - a. It is best applied in the hospital
setting. - b. It can be performed by a licensed social
worker. - c. It has been shown to delay early
diagnosis - at times.
- d. It involves a comprehensive
- multidimensional evaluation.
- e. It is a proven intervention for elder
- mistreatment.
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32Post-Test Questions
- In Texas, which of the following professionals
can determine decision-making capacity? - a. Social workers
- b. Police officers
- c. Prosecutors
- d. Physicians
- e. Psychologists
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33INTERVIEWING ELDERS AND ELDERLY VICTIMSPart B
Fine-tuning the Interview of Elderly Victims and
Perpetrators
Gregory Paveza, M.S.W., Ph.D. School of Social
Work University of South Florida
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34Pre-Test Questions
- 1. The 5 Ps of assessment are
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- a. Privacy, Pacing, Planning, Pitch,
Punctuality - b. Privacy, Pacing, Plumbing, Pitch,
Personality - c. Personhood, Pacing, Personality, Planning,
Pitch - d. None of the above
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35Pre-Test Questions
- 2. A classic neutralization technique is denying
responsibility. The abuser -
- a. Makes the victim out to be the wrongdoer.
- b. Says all people are hypocrites.
- c. Suggests the abuse is the result of forces
- beyond his or her control.
- d. Believes that abuse is inconsequential if
- no one is physically injured.
- e. Says that the abuse never happened.
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36Discovering the Problem
- The problem may come to light when
- you discover it.
- the caregiver discloses it.
- the patient discloses it.
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37Handling the Disclosure
- Let the discloser speak.
- Listen!
- Dont be distracted.
- Keep questions to a minimum.
- Watch for nonverbal clues.
- Accept natural silences.
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38Encouraging the Disclosure
- Who?
- What?
- When?
- Where?
- How?
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39Personally Dealing with the Disclosure
- Address confidentiality.
- Remember, your clients are adults.
- Respect your clients basic rights.
- Dont jump to conclusions.
- Avoid being judgmental.
- Avoid making accusations
- Observe the discloser.
- Avoid panic/keep calm.
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40Personally Dealing with the Disclosure (cont.)
- Avoid expressing shock or horror verbally or
nonverbally. - Consult as needed.
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41Monitor Yourself
- Pay attention to your own feelings of frustration
or fatigue. - If you get angry and upset because the person is
confused and does not understand, ask someone
else to be your mediator or to participate.
Remember the confusion is not deliberate,
regardless of how lucid the person was in the
past.
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42The 5 Ps of Assessment
- Privacy
- Pacing
- Planning
- Pitch
- Punctuality
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43Interviewing the Suspected Abuser
- Begin by saying
- This is a standard part of the assessment.
- You want to get all of the information.
- Information is needed in order to provide
services and help for the patient.
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44Critical Information
- Is there a presence of
- psychological, drug, or alcohol problems?
- physical illness?
- Does the caregiver have help?
- Is there a perceived burden in care giving?
- What is the caregivers perspective?
- What is the level of dependence on the client
- for finances?
- for housing?
- Gather details about possible exploitation.
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45Call the Question
- Based on the information collected, do you
believe abuse, neglect, or financial exploitation
is occurring? -
- If so, what are the next steps?
- Finally, document, document, document.
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46Neutralization
- Neutralization is when someone engaging in
delinquent behavior tries to justify it or make
it acceptable. - The tendency to try to make unacceptable behavior
neutral must be addressed.
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47Neutralization Techniques and Counters
- Denial of Responsibility
- Claim Abuse is accidental or the result of
forces beyond the persons control. - Counter Confront the abuser with the truth the
event could not have been an accident or caused
by someone or something else.
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48Neutralization Techniques and Counters (cont.)
- Denial of Injury
- Claim The abuse is inconsequential because no
one was really injured. - Counter Help the abuser to understand the nature
of the injury in terms of emotional or financial
consequences.
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49Neutralization Techniques and Counters (cont.)
- Denial of the Victim
- Claim The victim is the real wrong-doer.
- Counter The victims behavior is not an issue.
The abuser is responsible for harmful behavior
over which he or she had control.
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50Neutralization Techniques and Counters (cont.)
- Condemning the Condemners
- Claim All people are hypocrites. All people do
things that are wrong. People shouldnt stick
their noses in someone elses business. - Counter Nobody is perfect. This does not lessen
the seriousness of the offense or excuse it.
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51Neutralization Techniques and Counters (cont.)
- Appealing to Higher Loyalties
- Claim The victims loyalties are with me. Blood
is thicker than water. - Counter Its still abuse, and the victim must be
protected.
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52Neutralization Techniques and Counters (cont.)
- Defense of Necessity
- Claim The abuse was necessary to prevent some
greater evil. - Counter The abuser could have chosen other ways
to deal with the problem.
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53Neutralization Techniques and Counters (cont.)
- Metaphor of the Ledger
- Claim I deserve to have this be excused because
of everything Ive done for him/her. - Counter No amount of bookkeeping justifies the
abuse and the harm inflicted.
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54Final Thoughts
- Working with disclosure is difficult. Make sure
you have support. - Neutralization is common. Be prepared to deal
with it.
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55Post-Test Questions
- 1. The 5 Ps of assessment are
-
- a. Privacy, Pacing, Planning, Pitch,
Punctuality - b. Privacy, Pacing, Plumbing, Pitch,
Personality - c. Personhood, Pacing, Personality, Planning,
Pitch - d. None of the above
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56Post-Test Questions
- 2. A classic neutralization technique is the
denial of responsibility. The abuser -
- a. Makes the victim out to be the wrong-
- doer.
- b. Says all people are hypocrites.
- c. Says the abuse is the result of forces
- beyond his or her control.
- d. Believes abuse is inconsequential if no
one is - physically injured.
- e. Asserts that the abuse never happened.
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57Texas Elder Abuse and Mistreatment Institute
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